To Scribe or Not to Scribe? That is the question. While Shakespeare’s fictional character may have been contemplating something a bit more drastic than the decision to help providers with Electronic Health Records (EHR) by assigning clerical staff, it is worth noting that this particular issue may take more discussion than Hamlet’s seven soliloquies to resolve. It is clear that there are a number of variables contributing to success or failure in the use of scribes, and the setting seemingly most predictive of success is a large practice delegating significant responsibility to other staff.

When modeling, it seems evident that the use of scribes can improve productivity and provider professional satisfaction. However, there is little research to suggest that this actually happens in practice or, even if it does, whether it is cost-efficient. In addition, many arguments suggest that the use of scribes is simply an expensive “work-around” that reduces the pressure on vendors to improve the usability and functionality of their software systems, and that this practice will move the cost burden of inefficient programs from software vendors to health care providers. Further, the limited availability of truly effective scribes may limit health centers’ ability to implement programs.

In addition to the materials gathered for presentation in this article, a brief survey of members of Northwest Regional Primary Care Association (NWRPCA) provided information on the scope of the use of scribes in the Federally Qualified Health Center (FQHC) community. Findings from the study, which had 40 respondents, are presented throughout the article as appropriate.

WHAT EXACTLY IS A SCRIBE?

The first item to clarify is the proper role of a scribe and the content of the job. The role itself is not particularly original; many years ago “medical transcriptionists” were employed by physicians to keep paper records. However, the profession was nearly dying out until the introduction of EHR. As defined by the Association of Healthcare Documentation Professionals Group (AHDPG)[i], medical scribes:

…are individuals trained in medical documentation who assist a physician throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for…. Medical Scribe’s [sic] duties include performing all clerical and information technology functions for a physician in a clinic setting…[ii]

The organization has a more detailed prototype job description on its website. The list of responsibilities is worth noting here, because they provide a broader scope of potential responsibilities than simply following the provider around and entering data in EHR, and if practical, could offset some of the costs of additional staff:

1.Accurately and thoroughly document medical visits and procedures as they are being performed by the physician.

2.Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribes also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. [They] may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls and other clerical tasks as assigned.

3.Medical Scribes also spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician. Medical Scribes ensure that all clinical data, lab or other test results, [and] the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is complete.

4.Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. [They] will assist in developing and maintaining systems to track patient follow up and compliance.

It is clear that the requirements of documentation in EHR systems have become more and more burdensome. Physicians report that the primary advantage of EHR is an improvement in documentation (63%), while some of the other presumed advantages are less commonly noted: improvement in collections (39%), improved clinical operations (34%) and improved patient satisfaction (32%).[iv] The negative impacts of EHR are those generally experienced by providers in all settings: decreased face-to-face time with patients (70%) and decreased ability to see more patients (57%).[v]

Productivity unquestionably declines, often by as much as 25-33%[vi], during implementation of an EHR system. While some practice areas (such as Emergency Departments) may return to near-normal productivity following implementation, it has been shown that specializations critical to FQHC operations (pediatrics and family medicine) may never return to pre-implementation levels.[vii] Most of the published articles on productivity improvement seem to come from EHR vendors. However, a recent academic study[viii] concluded that actual improvement in productivity is not only possible, but can actually be shown. Critically, however, the study notes that productivity gains are correlated with:

·The size of the practice – larger practices are much more likely to see productivity improvements than smaller practices.

·The degree of delegation of clerical duties – the more duties are delegated, the more likely there will be improvements in productivity.

With most FQHCs tending to be small, and so far having had little use of scribes (of the participants in the NWRPCA survey, only 7.5% of the respondents reported using scribes) it is no surprise that the anecdotal evidence of permanent productivity losses in the industry is likely accurate. A recent study of medical provider productivity conducted by Merces, using published data, demonstrated that while weekly patient hours per provider have increased by about 10% over the past five years, both weekly encounters (-7%) and encounters per hour (-9%) have dropped sharply.

Impacts of EHR on Provider Satisfaction

Physician satisfaction with EHR is associated with overall professional satisfaction, according to a recent RAND Corporation Study[ix] . When EHRs were perceived as having negative impacts on their work (slowing clinical work, generating overwhelming numbers of electronic messages, interference with face-to-face patient care), physicians were the least likely to report high overall professional satisfaction[x]. Overall, 65% of physicians did not agree with the statement “our electronic health record improves my job satisfaction.”

A crucial trend noted in the study was that professional satisfaction decreased measurably when EHRs were perceived as requiring physicians to perform tasks that others could perform. Nearly two-thirds of the participants in the study (61%) reported that the EHR requires the physician to perform tasks that other staff could perform.

There is reason to believe that the situation is not likely to improve. In the RAND study, length of time since EHR had been implemented did not have a significant relationship with physician satisfaction, and it does not appear to be a generational problem, as younger physicians reported the same problems and frustrations as their older colleagues. The study notes numerous reasons why physicians’ professional satisfaction is worsened by EHR,[xi] and concludes, in part,

These findings suggest that the current state of EHR technology may be insufficient to deliver on the promise of EHRs. While there are some internal practice improvements that can be used, such as scribes, a larger system view is needed to improve the technology… [P]hysicians are optimistic about the future of EHR technology, but current inadequacies in the current (hopefully, transitional) state of EHRs must be addressed quickly.[xii]

Scribes as a Solution

The most adamant proponents of the use of scribes are providers of scribe services and training programs, but it is clear that physicians are also strongly in favor of their use. In fact, use of scribes has increased dramatically, and the industry expects to see its number to grow to more than 100,000 by 2020.[xiii] Published literature on the effectiveness of scribes in improving productivity seems to be primarily anecdotal, describing the amount of time lost in EHR data entry, and suggesting that scribes would “obviously” fix this; notably, the literature appears primarily on the websites of scribe providers or from individual organizations.

A white paper developed for a scribe service by KarenZupko & Associates, Inc., a Chicago based healthcare consultancy, notes that significant improvements in productivity are seen in Emergency Departments when scribes are used. Less of a “study” than a collection of the anecdotal experience of consultants of the firm, the authors suggest that a scribe in a primary care setting could conservatively be expected to allow a physician to see one additional patient per hour during an 8-hour clinical day.[xiv]

The RAND Corporation study noted that physicians using scribes display less opposition or frustration with EHR, and reported higher levels of professional satisfaction. Other studies suggest that the patient experience is improved when a scribe is in the room.[xv]

But Which Scribe is the Scribe that Achieves Positive Results?

The studies that speak to the improvements in productivity typically describe the scribes as being primarily pre-medical or nursing students. However, it appears that the majority of scribes currently in the job market, or to be processed through training and certification programs in the future, will be far less qualified. In a “viewpoint” article posted on the website of the Journal of the American Medical Association, the physician authors note that the American College of Medical Scribe Specialists (AMCSS), a tax-exempt organization representing scribes and hospitals, will be calling for significantly less training than the college students referenced above receive:

The ACMSS, whose leading financial sponsor is ScribeAmerica, states on its web page that “the process of selecting a potential Certified Medical Scribe is complex and that ‘ACMSS provides the groundwork for excellence throughout the industry.’” Yet it also stipulates that “minimum requirements include a high school diploma or G.E.D. [and that] each company sets their [sic] own criteria for hiring and selection process.” ScribeAmerica’s training program involves a 2-week orientation, a supervisory period under a “highly experienced” medical scribe, and periodic reassessment of the scribe’s effectiveness. PhysAssist Scribes emphasizes that “great scribes aren’t just born – they’re made,” so it established a “scribe university… a five-day training program unlike any other in the industry.”[xvi]

It seems evident that inexperienced scribes could not possibly achieve the productivity and quality improvements found with more professional clinical staff, and that a certification program based on passing an open book test and signing an affidavit that the individual has worked a specified number of hours as a scribe under supervision is not likely to ensure the effectiveness of an individual on the job.

THE CASE AGAINST HEALTH CENTERS USING SCRIBES

Clearly a case can be made that the effective use of properly trained scribes, in the proper setting, can potentially improve both physician productivity and professional satisfaction. The question, of course, is whether this can realistically happen in the typical health center environment. As noted above in the RAND Study, productivity is likely to improve in larger practices which have made a commitment to EHR and who employ highly qualified scribes. Smaller practices, typical for many health centers, and those without the resources to deploy highly skilled individuals, may find it tempting but unrealistic in practice.

Staffing and Scheduling

Among the many issues to resolve in the deployment of scribes is how the function will be staffed. Considerations include:

·What should be the ratio of scribes to providers? If a full-time provider needs a full-time scribe, when will the scribe’s non-clinic clerical duties be performed? It is unlikely all the duties listed in the job description above can be performed along with working six to eight hours with the provider in a clinic.

·Will scribes be assigned to specific providers? This will clearly be a close working relationship, and the differing styles of providers may suggest that a provider who works with only one scribe would be more effective. What happens then when the personal scribe is unable to work? What happens if the provider and the scribe do not get along? What about part-time providers, and those with unusual schedules? Will there be an attempt to hire scribes to match the schedules of providers, or will there be a pool for those who are not full time?

·Where will scribes be found? The literature seems to indicate that pre-medical and nursing students are ideal to function as scribes. In many rural settings, it is difficult to find qualified employees at all, let alone college students. If they can be found, they will also likely be leaving when their studies are over. Will the scribes provided by the one or two week certification programs be adequate? It is hard to imagine the typical health center having the resources to establish a training program for such a job. What about the possibility of using current employees (e.g., Medical Assistants) and training them to be scribes? A possibility, yes, but the health center will then have to find a way to replace the Medical Assistant.

Health centers are known for being creative in combining roles and responsibilities, but a great deal of care should be taken when considering combining clinical and clerical roles in the same person. An article published on the website of the American Health Information Management Association (AHIMA) includes a good description of the potential mess to be made when combining clinical and clerical roles.

The role of a scribe is dependent upon the provider practice and setting. It is possible for a provider to select a clinical assistant (non-licensed clinical staff) who has performed clinical duties and worked with the provider to perform scribe services. It is not recommended, however, to allow an individual to fill the role of scribe and clinical assistant simultaneously during the same encounter. This practice raises legal and other issues regarding job role and responsibilities.

EHR security rights (role-based access) for a scribe and clinical assistant are different. Scribes have nearly the same security rights as a provider, while a clinical assistant enters information independently and only within the individual’s scope of practice. Thus, the individual security rights are more limited for clinical assistants than those of the provider and must be considered in the decision-making process.

When a scribe is also acting as a clinical assistant during the same encounter, the scribe will log in with one set of security rights as a clinical assistant, log out, and then log back in with another set of rights to perform the scribe duties. The dual role results in the scribe logging in and out between roles multiple times during one encounter – wasting valuable time and resources. To avoid this situation, some practices limit the scribe to filling only one role during a single encounter.[xvii]

While the use of an appropriately trained clinical assistant to fill in for a scribe might be a reasonable solution in emergencies, it does not seem to be an approach to use on an on-going basis.

Staffing and scheduling of scribes present many challenges. It is clear that a larger health center will have a much easier time setting up a flexible program, and equally likely that small practices will face major challenges.

Limitations on the Duties of the Scribe

A significant problem, and one for quality and risk management staff to consider carefully, is ensuring that scribes perform only those functions for which they are permitted, by the appropriate laws, regulations and agencies.

The Joint Commission neither endorses nor prohibits the use of scribes. It does, however, place limitations on what scribes may and may not do. Compliance with the Record of Care and Provision of Care standards also apply and include, but are not limited to:

Signing (including name and title), dating of all entries into the medical record—electronic or manual (RC.01.01.01and RC.01.02.01). For those organizations that use Joint Commission accreditation for deemed status purposes, the timing of entries is also required. The role and signature of the scribe must be clearly identifiable and distinguishable from that of the physician or licensed independent practitioner or other staff.

The physician or practitioner must then authenticate the entry by signing, dating and timing (for deemed status purposes) it. The scribe cannot enter the date and time for the physician or practitioner. (RC.01.01.01 and RC.01.02.01)

Although allowed in other situations, a physician or practitioner signature stamp is not permitted for use in the authentication of “scribed” entries-- the physician or practitioner must actually sign or authenticate through the clinical information system. (RC.01.02.01).

The authentication must take place before the physician or practitioner and scribe leave the patient care area since other practitioners may be using the documentation to inform their decisions regarding care, treatment and services. (RC.01.02.01 and RC.01.03.01)

Authentication cannot be delegated to another physician or practitioner.

The organization implements a performance improvement process to ensure that the scribe is not acting outside of his/her job description, that authentication is occurring as required and that no orders are being entered into the medical record by scribes. (RC.01.04.01).[xviii]

Another risk raised by Dr. Gellert in the JAMA article is with Computerized Physician Order Entry (CPOE). The Joint Commission states clearly that it does not support scribes being used to enter orders for physicians or practitioners due to the additional risk added to the process.[xix] The Centers for Medicare & Medicaid Services (CMS) states:

We disagree… that anyone should be allowed to enter orders using CPOE. This potentially removes the possibility of clinical decision support and advance interaction alerts being presented to someone with clinical judgment, which negates many of the benefits of CPOE.[xx]

Third-party payers may also have specific guidelines for documentation and how electronic signatures are applied.

Physicians themselves may disagree on whether CPOE is a clerical or professional function. According to Gellert:

Another risk is unintentional or intentional functional creep in how medical scribes are used. Although the Joint Commission prohibition on use of scribes for order entry is unequivocal, some physicians still advocate use of medical scribes for CPOE. The Joint Commission cannot monitor whether medical scribes are used for order entry by US physicians… According to an anecdotal account, scribes working at some of the nation’s largest scribe companies reportedly have been instructed by physicians to document certain activities, such as counseling smoking cessation, not actually performed to increase billable charges, to avert administrative compliance pressure, or both. Scribes, wishing to retain their jobs, ordinarily cannot decline such directives to enter orders in CPOE. For physicians who regard CPOE as clerical, use of medical scribes for order entry could be rationalized. Even physicians who understand that prohibition may, under pressure of a busy practice, ask a scribe to enter verbal orders. There is substantial risk of unintended functional creep, of letting scribes enter verbal orders, rather than having another licensed user enter orders.[xxi]

Those in management responsible for compliance must ensure that the requirements of the Federal and State governments, as well as their accrediting agencies, are followed closely.

Will Productivity and Professional Satisfaction Actually Increase?

If difficulties with EHR are a significant cause of physician dissatisfaction, as documented above, surely anything that is done to reduce the burden or to better allocate tasks that need not be performed by the physician would be advantageous. If EHR reduces productivity, surely anything that improves productivity would be welcome.

Participants in the NWRPCA study certainly felt that way – while not an option on the question regarding the positive outcome of the use of scribes, 30% wrote in some reference to improved provider satisfaction. Nearly 90% felt that productivity would be improved, and they expected other positive results – improved billing/reimbursements (52.6%), better clinical care (47.4%) and higher quality customer service (42.1%).

A major, and very realistic, concern is that health centers will not be willing to invest in the level of skills necessary to achieve the results the NWRPCA respondents expected. In addition to the negative impact of EHR on professional satisfaction, the RAND study highlighted the fact that having long-service, highly skilled support staff is key to satisfaction:

Working with adequate numbers of well-trained, trusted, and capable allied health professionals and support staff was a key contributor to greater physician professional satisfaction. Support from such staff enabled physicians to achieve a more desirable mix of work content. Several study participants appreciated having long-term working relationships with allied health professionals and support staff, with some such relationships spanning decades. This theme was corroborated in quantitative analyses of physician survey responses, which revealed that greater staff stability (i.e., lower turnover) was a significant predictor of better overall professional satisfaction.[xxii]

Many providers already express dissatisfaction with the quality of support staff and the high level of turnover that often occurs in the health center environment. Whether caused by an inability or unwillingness to pay competitively, a dearth of qualified individuals in the community, or insufficient training and management support, there is a concern that retaining skilled, long-service scribes might not be realistic. With providers already concerned about the quality and turnover of support staff, adding yet another role, and one that would require the utmost trust and confidence on the part of the provider, might very well have the exact opposite effect – decreased productivity and professional satisfaction.

Patient Privacy Concerns

A practical concern is whether the presence of another individual in the examination room could cause patients to be uncomfortable. Some of the studies referenced note this concern in passing, but in general seem to concur that this is not an issue. However, it is also important to remember that these studies were not conducted in primary care settings where there are many challenges, and where patients may have cultural and other concerns.

The issue of opposite gender examinations can be resolved by having the scribe leave the examination room during intimate examinations, communicating to the scribe through a microphone and earpiece.

Reduction in Pressure on Software Providers

Numerous sources reviewed in this study confirm that many EHR systems are unwieldy and overly complex and lack usability. The competitive pressure exerted by users might have been expected to have caused vendors to develop improved systems, but anecdotal evidence suggests that the systems are not improving, and may be becoming more difficult and time-consuming. They are certainly not considered easy to use. Many well-known products, even those used by NWRPCA member health centers, have been rated “below average” and barely “average.” None of the most widely used products had ratings more than 0.2 points above “average.”[xxiii]

The focus on the problems with EHR is not to suggest that scribes will solve the problems – all the use of scribes will do is transfer the problems with the systems to someone else, fundamentally doing nothing to improve the situation, and merely adding costs to the end-users. This situation is no different from any other “work-around” – it is something a user does to bypass a problem with a product. If users are able to return to pre-implementation productivity through the use of scribes, they may be less likely to shop around for more effective products, putting less pressure on the software industry.

The Elephant in the Room – The Cost

The cost of providing scribe services to providers is a direct addition to the cost of EHR; while arguably the cost of scribes may be balanced by an increase in productivity and revenue capture, this appears likely to occur only in the ideal setting. Effectively this means, to potentially achieve the desired results, health centers would have to hire the most skilled, and likely most costly, scribes available.

Scribe services vary dramatically in price, as would be expected given the wide range of possible qualifications. Outsource services appear to charge between $14 and $23/hour, presumably the price in larger metropolitan areas where such a service is practical. There are also “virtual scribe” service providers (yes, based in India), who may cost less, and might feasibly be used if the EHR is “cloud-based.”

While competitive published data on scribe compensation is limited, the hourly rates currently reported for medical transcriptionists are between $15 and $20/hour.[xxiv] The scribe training programs suggest to potential students that they will earn at least $25/hour, which seems untenable for a position requiring only a high school education and a week or two of training. While of limited value, some of the online pay sites (e.g., glassdoor, payscale) report more realistic rates of $8 to $12/hour.

Various studies focus on the cost-benefit analysis of scribes in emergency departments, many of which indicate a clear cost benefit to the use of scribes, and some of these are cited by scribe services. Most cost-benefit analyses in a clinic setting are not the results of actual studies, but are simply created based on assumptions of the costs of scribes and the results of using them. Generally these predict a “break even” at somewhere between one additional patient per hour, and one additional patient every three hours. The variance is due to assumptions concerning the cost of scribes (as well as whether they are subcontracted or hired directly) and the amount of time saved. Critical to believing these assumptions, however, is the fact that, at least as of late 2013, there had not been a single actual controlled study of scribe use in a clinic setting.[xxv]

The first prospective controlled study assessing the clinical and financial aspects of using scribes in a clinic setting took place in late 2013 at the United Heart and Vascular Clinic (UHVC) in Saint Paul, Minnesota, owned by Allina Health. UVHC is a large practice of 25 cardiologists and four nurse practitioners who had been using EHR for about four years. The study,, following four physicians during approximately 130 hours of clinical observation (65 with scribes and 65 without), concluded that “using scribes in a cardiac clinic is feasible, produces improvements in physician-patient interaction, and results in large increases in physician productivity and system cardiovascular revenue.”[xxvi]

What is critical to understand about the study is its limitations. It involved four experienced physicians who volunteered to participate in the study. The study did not measure changes from historical productivity levels, but only the differences in productivity between “scribe days” and “regular days” in about a four-day period. The scribe used had six years of experience (albeit none in cardiology, but was provided three hours of training). Further, the schedules changed – on regular clinic days, patients were scheduled 20 minutes for follow-up appointments and 40 minutes for new appointments, while on scribe days, patients were scheduled 15 minute slots for follow-up and 30 minutes for new patients. How much the scheduling itself impacted the results cannot be determined.

The authors fully admit the limitation of the study, and note that the effects of the proposed models using scribes requires further investigation.[xxvii] Of significant concern is how the results of this single small study would transfer to a primary care setting

The Downside Expressed in the Survey

The participants in the NWRPCA survey expressed concern with the use of scribes in their clinics. More than half (54%) believed that the costs would outweigh the benefits, and just under half (46%) expected there would be more errors in the EHR. Other concerns raised by the participants included the difficulties faced in finding scribes with the right skill sets, the lack of physical space in examination rooms for an additional person, concerns with finding bi-lingual/bi-cultural scribes, provider rework and, notably, the need for training.

CONCLUSION

The use of scribes may be a work-around solution to the problem of EHR software that has not met its promise. Successful use of scribes requires careful thought and planning, and would require retaining trained scribe staff, and delegating significant responsibilities to them. As noted previously, it is most likely to be a success in larger practices.

More than half of the respondents to the NWRPCA survey (55%) believed their organizations were unlikely or definitely not going to begin using scribes. The comments made by the participants outline the context for further study and, particularly, for more exchange and dialogue with those who have used scribes.

Whether the additional costs will be offset by savings is unknown. While models and predictions seem to make sense, they should be judged with extreme caution if they are presented by the very vendors who seek to provide scribe services. As there appears to have been no actual research on the use of scribes in a primary care setting, there is nothing to work from beyond a clinic’s own experience or that of its peers.

As Gellert argues, in the conclusion of his article:

The answer to today’s inadequate EHRs is not scribe support. Instead, physicians should demand improved products, should educate vendors to ensure that they understand how physicians think clinically, and should clarify what is needed for an intuitive, quick, and navigable user interface…. The medical scribe industry may impede the technological evolution of EHR products by undermining market demand for needed improvement, and it is unlikely that scribes will be used only as a temporary solution. The rise of the medical scribe industry should not be a substitute for much-needed EHR innovation and transition to more highly effective and more functionally efficient EHR systems [emphasis added].[xxviii]

NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U58CS06846, "S/RPCAs," total award $950K, with 65 percent of program funded by nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.